HomeMy WebLinkAboutMIS97-0426 Change of Use - MIS Application - 6/16/1997 Ohaz �q
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MASON COUNTY
MISCELLANEOUS PERMIT APPLICATION
426 W. Cedar/P.O. Box 186, Shelton, WA 98584 • 427-9670
PLEASE PRINT
#1 Owner A'J&[ AtL" Phone# 3t 2?7 09 fjLl Fire District#�
Site Address Qe Z30 1-ko sw�, (LTA City
Mail Address �•v Bo,� Z� z
City St w Ar Zip
Applicant '4't." Phone # 34eo G4 S 04-4�
Applicant Address BSc. T".,,...hx'z a0.,�
City St t�JA- Zip
Directions to Site: S'T�TE 3 ,4,'efcs_ , �G�D Aoe,'4,�y
#2 Parcel No. i z329 - 4/ - ov r 6 d
Legal Description 4 77-0 h,J
#3 Indicate by circling the applicable s rce n �yw �r, jacent to the property site:
saltwater lake river cr poneasonal runoff marsh other
#4 Project Start Date - N Ia Project Completion Date
#5 Use of Buildiing e o 12 V I� pp Describe proposed construction
'Depending upon the type of permit,a floor plan and plot plan may be required.
'This permit is valid for 180 days from the date of issuance.
OWNERS AFFIDAVIT CONTRACTORS AFFIDAVIT
I CERTIFY THAT I AM EXEMPT FROM THE REQUIRE- I CERTIFY THAT I AM A CURRENTLY REGISTERED CON-
MENTS OF THE CONTRACTORS REGISTRATION LAW TRACTOR IN THE STATE OF WASHINGTON AND I AM
RCW 18.27, AND AM AWARE OF THE MASON COUNTY AWARE OF THE ORDINANCE REQUIREMENTS REGULAT-
ORDINANCE REQUIREMENTS FOR WHICH THIS PERMIT ING THE WORK FOR WHICH THE PERMIT IS ISSUED AND
IS ISSUED AND THAT ALL WORK DONE WILL BE IN CON- ALL WORK DONE WILL BE IN CONFORMANCE THERE-
FORMANCE THEREWITH.NO CHANGES SHALL BE MADE WITH. NO CHANGES SHALL BE MADE WITHOUT FIRST
WITHOUT FIRSTOBTAINING APPROVAL FROM THE BUILD- OBTAINING APPROVAL FROM THE BUILDING DEPART-
ING DEPARTMENT. f MENT.
X OWNER '~-� X BY
DATE (Q�/(p DATE
Show following on the site plan
Lot Dimensions Flood Zones
Existing Structures Fences
Structure Setbacks Wells
Water Lines Shorelines
Drainage Plan Easements
Septic Systems Name of Fronting Street Indicate directional by
Proposed Improvements Name of Flanking Street N, S, E, W etc.
PLOT PLAN AREA
FOR OFFICIAL USE ONLY:Accepted by: Date:
DEPARTMENTAL REVIEW
FOR OFFICIAL USE ONLY
PlanningA APP COND APP HOLD
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Building C kt"Xe U s E Ll Ed SRFTct R,0V 1-d LJ 0
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Fire Marshal
Other
Special Conditions Fees
Permit Fee $ ;33. OCR
Plan Check
Other
Other
State Building Fee
TOTAL DUE $
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CHANGES
SUBMIT CHANGES FOR APPROVAL
PRIOR TO PERFORMING WORK
IJ a-r t: Ek cs rTrr f3 u t.c.e I nr G-
NO'T CK14M Cr►w !. RttY 10 LuMl3 tNG .
$F 50 MAX I.T W cer R-L(- K►1N0<�App ro At C C-SS (b
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CURRENT L-�" PLANS MUST BE APPROVED
MUST MELT ALL UA THE JOB SITE MASON BUILDING INSPECTOR
WASHINGTON STATE CODES ;-`,P INSPECTION. CHANGES SUBJECT TO APPROVAL
(�L _DATE f'742711
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